Fillable FORM APPROVED: REQUEST FOR EXEMPTION OF SELECT AGENTS (Department of Health and Human Services)

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FORM APPROVED: REQUEST FOR EXEMPTION OF SELECT AGENTS (Department of Health and Human Services)

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REQUEST FOR EXEMPTION
OF SELECT AGENTS AND TOXINS FOR
AN INVESTIGATIONAL PRODUCT
(APHIS/CDC FORM 5)
FORM APPROVED
OMB NO. 0579-0213
OMB NO. 0920-0576
EXP
DATE 10/31/2020
Read all instructions carefully before completing the form. Answer all items completely and type or print in ink. The form must
be signed and submitted to either APHIS or CDC:
Animal and Plant Health Inspection Service Centers for Disease Control and Prevention
Agriculture Select Agent Program Division of Select Agents and Toxins
4700 River Road Unit 2, Mailstop 22, Cubicle 1A07
1600 Clifton Road NE, Mailstop A-46
Riverdale, MD 20737
Atlanta, GA 30329
FAX: 301-734-3652
FAX: 404-718-2096
E-mail: AgSAS@aphis.usda.gov
E-mail: lrsat@cdc.gov
SECTION 1 – TO BE COMPLETED FOR INVESTIGATIONAL PRODUCT EXEMPTION
1. Entity name:
2. Entity registration number (if applicable):
3. Entity address (NOT a post office address):
4. City:
5. State:
6. Zip code:
7. Applicant
First: MI: Last:
8. Title:
9. Telephone #:
10. FAX #:
11.
E-mail address:
12. FDA IND/INAD/IDE number:
13. FDA product name:
14. This product has been approved for Phase I clinical trials
by FDA: No Yes
15. Date of the IND/INAD/IDE application submitted to FDA including the name of the FDA center and review office
FDA Center/Review Office: Date:
16. USDA veterinarian product code number:
17. USDA veterinarian product name:
18. This product has been tested and approved for field trials
by USDA: No Yes
19. Investigational product (Give select agent name and characterization):
20. Federal act that authorizes investigational use of this product:
21. Provide a detailed justification to request an exemption for the use of an investigational product that is, bears, or contains select agents or toxins
(attach additional sheets if necessary):
I hereby certify that the information contained on this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a false
statement on any part of this form, or its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of 7 CFR
Part 331, 9 CFR Part 121, or 42 CFR Part 73 may result in civil or criminal penalties, including imprisonment. For exemption requests that involve the
investigational product that is, bears, or contains select agents or toxin, I authorize FDA to confirm for APHIS or CDC the existence and status of the IND,
INAD, or IDE, and agree that such confirmation will not violate FDA's information disclosure regulations, the Federal Food, Drug, and Cosmetic Act, or the
Trade Secrets Act (18 U.S.C. § 1905).
Signature of Investigational Product Exemption Applicant: ________________________________________________ Date: ________________
Public reporting burden: Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently
valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0576).
APHIS/CDC FORM 5 (11/30/2018)
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FORM APPROVED: REQUEST FOR EXEMPTION OF SELECT AGENTS (Department of Health and Human Services)

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Completed 26 January 2021

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